National Alliance to End Homelessness. (2014). Cost of Homelessness. National Alliance to End Homelessness. Retrieved April 8th, 2014, from http://www.endhomelessness.org/pages/cost_of_homelessness

National Health Care for the Homeless Council. (2014, March). NHCHC Infographic. National Health Care for the Homeless Council. Retrieved April 8th, 2014, from http://www.nhchc.org/wp-content/uploads/2011/09/nhchc-infographic.pdf

"I'm not a bum, I'm a human being."- If we can stand in their shoes, hear what they hear, see what they see, feel what they feel, then we will treat them differentlyPhotos SourcesFacebook. (2013). Sonder. Retrieved from https://www.facebook.com/photo.php?fbid=433431990125976&set=pb.252006304935213.-2207520000.1398310409.&type=3&theater

Oprah. (2010). Treat the homeless with dignity [Photograph]. Retrieved from http://www.oprah.com/spirit/Treat-the-Homeless-with-Dignity-Every-Monday-MattersNeed a summary? Take a look at your handout! All our points and available resources for you can be found there.EducationAs we know, education is a vital part of our jobs as nurses.

However, in this instance, it's not just our homeless patients who need education; it's also us - the nurses.www.jacksonnursing.comNurse EducationNurses need to be educated on how to treat the homeless population when they're directly under our care.www.oprah.comTips for Good CareTreat them with dignity and respect, just as you would any other patient. They are humans too and their life means just as much to them as your life means to you.Put yourself in their shoes. Picture yourself going through their experiences, facing what they're facing, and see how your life would turn out. Would you make the same decisions? Would you be fighting the same battles?Treat these patients with compassion. As you saw in the video earlier, homeless are often treated with disrespect. The very word nurse stems from the word nourish, which means "to feed".Take very good care of their "things". They don't have a lot of "things". So even if they have strange "things" that may not mean anything to us, they may be treasured possessions to our patients. Be aware of their personal space. Homeless people may not be comfortable with people touching them/being so close to them.Remember these people may have a lot on their plate. They may be dealing with addiction, loss of friends/family/job, mental illness, less education, etc. So don't assume they can handle as much as other patients. And don't assume they can't handle it either. It's a fine line between treating them like children and treating them like adults who have lost everything.Finally, listen to them. Our homeless patients may have a lot to say, or they may have nothing to say at all. Listen in the silence and tend to their needs. Maybe all they need is another human to pay attention to them.

Patient EducationAs we said before, health problems cause 60% of all bankruptcies. This puts a person at a higher risk for homelessness.

If we can disrupt this process at least a little bit, our patients may be able to keep their heads above water.Educate our patients THOROUGHLY on their chronic disease. Teach them how to manage it, how to fit it into their lifestyle, how to continue working in the midst of it, how to be cost effective, and where they can find resources/support.Refer "at risk" patients to financial services. We can't be the experts at everything all the time.Thoroughly educate our patients in preventative care. Simply being homeless opens SO many doors to poor health. Tell them what they're at risk for!Make them care about their health! Don't forget to tend to every aspect of their health- not just the physical needs. There's also environmental, spiritual, emotional, and mental. For the homeless population, all five of these aspects may be lacking in sufficiency.How do we do this?Possible Nursing DiagnosesImpaired home maintenance r/t cognitive or emotional functioning, inadequate support system, insufficient financesSelf-neglect r/t mental illness, substance abuse, cognitive impairmentPowerlessness r/t interpersonal interactionsRisk for trauma r/t being in a high-crime neighborhood, etc.HopelessnessDeficient community health r/t lack of access to public health care providers, inadequate community support (pg. 406)Risk-prone health behavior r/t excessive alcohol, inadequate comprehension, inadequate social support, low self-efficacy, low socioeconomic status, multiple stressors, smoking, negative attitude toward health care

Sunrise Family Clinic44% uninsured39% medicaid7% private6% child health plan4 % medicareprimary medical and dental carebehavioral health sciencesWIC, nutrition, and health educationspecialty servicesoutreach servicesSunrise Offers:97% live at or below 200% of poverty level (family of 4 earning <$46,000/yr)71% live at or below 100% of poverty level(family of 4 earning <$22,050/yr)overnight emergency sheltertransitional housing shelterdaily mealsclean linens/basic toiletriescase management and referralscomputer resource roommedical screenings/referrals to SunriseGuadalupe Centerserved 555 individuals14,927 nights of shelter65% of clients were able to secure sustainable housing after leaving the shelterGuadalupe StatisticsEmergency Food Box Programany resident is eligible (ID, SS)don't need proof of incomenon perishable & available perishable from food roomWeld County Food BankWeld County Food BankMobile Food PantryTaking food directly to the people in needDelivers: fresh produce, dairy products, meat, bakery, and dry goodsPinpoint areas with the highest needOther programs:Commodity supplemental food programKid's programs*Physiological & Safety needs*What can we do?Q & A with Karen HesslerQ: Does your care change when you have a homeless or transitional homeless patient?NP volunteers for SunriseA: "It changes everything" many are transitional, living in a friend's, parent's, or acquaintance's housemust prescribe and treat in cheapest and most cost-effective mannersocially - can they pay $4 for medication, can they get to appointmentsQ: Is there any advice you would give student nurses in preparation of caring for these patientsA: Meet them on their levelthey are intelligent - usually they are this way due to abnormal circumstances and have just fallen down on their luck"they aren't losers," break the stereotypereach each person with a caring attitudedo not be judgemental - these patients see a lot before they get to youQ: How does Sunrise work with the people that cannot afford care?A: Many of the providers are volunteer, there is a sliding scale payment system, they accept Medicaid and MedicareOther:working here has really changed her attitude toward the word "poor." psych disordersmental health: self esteem, embarrassment, shame, self worth

Causes of Homelessness

Nowhere in the 50 states can a person work a full-time, minimum wage job and afford fair market rent, even for a one-bedroom apartmentHealth problems cause 60% of all personal bankruptcies, which frequently leads to homelessness

Compared to non-homeless, psych disorders occur 3-4x as frequently, and co-occurring substance abuse occurs 5x as oftenWhether occurring before or after, mental illness significantly handicaps a person’s ability to reintegrate into society and find workMany homeless individuals would be able to hold down a job if they had access to healthcare and medicationsA Sample from the StreetOn any given night, more than 636,000 individuals in the U.S. have no place to sleepOn the streets, there are 2 males for every 1 female40% are Caucasian, 40% are African American20% are <18, 20% are in their 20’s, and 40% are between 30 &50

At-Risk PopulationsIn a year, 1,500,000 children experience homelessness...alone50% of youth experienced physical abuse, and 30% sexual abuse, that resulted in homelessnessThese youth often remain homeless chronically because they lack the education necessary to market themselves for a job; this in turn puts their health in dire straitsWomen & Children40% of the homeless population is made of families with children - 80% are single mothers90% of homeless mothers have been physically and/or sexually abused50% of mothers developed major clinical depression AFTER becoming homeless

Unaccompanied YouthAfrican-American MenCulturally, the man bears the responsibility of financial provision for the family, no matter the costDelaying personal medical needs in order to provide for the family is expected in this cultureA significant proportion of men in low-income African-American families leave in order to allow their families to qualify for public assistance and have a chance at survivalas studied by Hill, et al. 2011Financial SituationMental Illness & Substance AbuseThe Health of the HomelessExposure to infections and communicable diseasesShelters or lack of housing result in poor hygiene and frequent human contact, leading to easy pathogen transmissionHomeless are more likely to suffer from: Parasitic skin infections and conditionsGI illnessesRespiratory infections, esp TB STIsIncreased incidence of chronic disease

Nearly 50% of homeless suffer from a chronic health conditionStress, diet, drug use, disability, and mental illness all increase their risk of developing chronic illnessAs expected, high rates of diabetes, obesity, anemia, asthma, HTN, COPD, PVD, and chronic liver and renal disease is reported among homelessIt is difficult to determine whether the illness caused or followed homelessnessIncreased incidence of psychosocial problemsWithin the chronically homeless population, 60% suffer from a severe psych condition and 80% are consumed by drug/alcohol issues Mental illness exacerbates the physical effects of communicable and chronic diseaseLimited access to health servicesPreventative services – immunizations, cancer screening, prenatal careMedical & surgical carePrescription medicationsChronic disease management & follow-up careMental health care & follow-upEye & dental careEmergency Department20-30% of all ED visits are made by homeless individualsED is overused by this population because all healthcare is either treated as emergent or is nonexistent80% of ED visits by homeless people could have been prevented with primary care provided free of charge or at reduced ratesHospitalizationHomeless individuals are admitted from the ED to inpatient units 5x as frequently as non-homelessHomeless individuals spend, on average, 4 days longer per hospital visit than non-homelessThe rate of psychiatric hospitalization for homeless is 100x that of non-homelessSeeking HealthcareChronic homelessness – On the streets for a year or longer without reprieve

Transitional homelessness – Temporary, one-time stay, usually in a shelter, before returning to society

Episodic homelessness – Teetering between life on the streets and life within society, often due to povertyTypes of HomelessnessOverview of the HomelessWhy THIS group?- Our goal is to understand who they are and the reality of their lives, as none of us have experienced this culture- The homeless compose a diverse group regarding gender, race, and age - it is hard to provide care for a group we have little in common with- We want to be prepared in case we encounter the culture of homelessness in the future- This group has significant risks in terms of health issues, making them an important focus for nursesAdapting to HomelessnessNursing Focus- For this group, attention should be paid not only to the illness, but also to the person's situation in life-Our goal should be to increase the well-being of our patients in terms of helping them to recover from their illnesses- Homeless individuals tend to be misjudged and misunderstood, and this impacts their access to healthcare- The culture of the homeless is one of adaptation - while people enter homelessness with their own norms and customs, these must change in order to meet their needs- The move into homelessness can be gradual or sudden, affecting how they adapt to their new environment- Gradual transitions appear to be somewhat less jarring by allowing the opportunity to mentally prepare for the change- Individuals can form close-knit groups in order to meet the needs of the population as whole, uniting people with nothing more in common than their homelessnessRank & Hierarchy- Just as with other cultures, a rank system emerges among homeless individuals as well- The values that create the leader in the homeless population are the opposite of what establishes power in mainstream culture- Respect is awarded to those who have experienced the most trauma and survived the longest on the streets- Pain and trauma become badges of honor, with women touting the number of times they have been raped, or criminal records advertised to demonstrate strengthFriendship- With homelessness comes isolation from mainstream society, and strong bonds are created amongst members of the homeless culture to compensate- Due to the circumstances of homelessness, having few ways to spend their time, and constant contact with other people, friendships can form amongst even un-similar individuals- Friendships that arise between homeless people have a quality of empathy and understanding that they may not have received from mainstream society- They are able to relate to life circumstances and support one another- They build trust through shared life experiences and the knowledge that the other will not pass judgment upon themValues & Characteristics- Distrust & breakdown of personal control- Safety & survival - focus on the environment & how it affects them- Present time orientation - daily existence rather than looking ahead or looking back- Self-focused existence - despite friendships, the most important person is himself/herself- Altered perception of ethics - all is permissible if done for the sake of survival, whether theft, murder, prostitution, etc.- Resentment & anger against society - because of their place outside of it- Violence - seen as an acceptable way to fix a problem between two or more people- Accept their definition of family and friends - ask who should be allowed in their room & who can access their medical records- Adjust our interactions & recommendations to account for limited access to food and housingCulture of the Homeless

Lobby, lobby, and more lobbyingLobbyists are typically employed by interest groups that want public policies to favor them and their causes. The goal of healthcare lobbyists is to impact healthcare policy to facilitate effective use of human and financial resources.

The process of lobbying involves an active constituency to make elected official accountable for their vote. Advocacy!

Lobbyists most often use verbal persuasion to try to influence public officials. Interest groups may hold a formal meeting where information is shared that supports their position on a topic.

A lobbyist might try to befriend public officials in various ways, such as by taking them out to dinner, throwing parties or providing entertainment. Unfortunately some might resort to more unethical or even illegal practices, such as bribery.Strategic Political Influence Rank

12345678910

Democrats/Democratic leaners

The economyEducationPoverty and homelessnessHealthcare policySocial Security and MedicareDistribution of income/wealthCrimeThe environmentTerrorismGun policyRepublicans/Republican leaners

The economyTerrorismThe military and national defenseHealthcare policyEducationTaxesSocial Security and MedicareCrimeImmigrationWorld affairsPoverty and homelessnessTop 10 Priority Issues, by Party IdentificationThese results are from Gallup's annual Mood of the Nation survey conducted January 5-8, 2014. They are based on telephone interviews conducted with a random sample of 1,018 adults ages 18 and older, living in all 50 U.S. states and the District of Columbia.Affordable Care ActMental Health AmericaResourcesNational Coalition for the Homeless (2008). Factsheet for college students. National Coalition for the Homeless. Retrieved April 8th, 2014, from http://www.nationalhomeless.org/factsheets/Fact%20Sheet%20for%20CollegeStudents.pdf

Phillips, K. (2012). Homelessness: Causes, culture, and community development as a solution. Pell Scholars and Senior Theses, 88. Retrieved from http://digitalcommons.salve.edu/pell_theses/88

Substance Abuse and Mental Health Services Administration. (2011, July). Current statistics on the prevalence and characteristics of people experiencing homelessness in the united states. Substance Abuse and Mental Health Services Administration. Retrieved April 8th, 2014, from http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf

Expanding coverage: No one can be denied insurance coverage based on preexisting conditionsMedicaid expanded to 133% of the federal poverty level which is about $14,000/yearMental Health and Substance Use: (essential benefits)Preventive services:For adults: alcohol misuse screening and counseling, depression screening, and tobacco use screening and cessation interventionFor women: domestic and interpersonal violence screening and counseling, expanded tobacco use, and counseling for pregnant womenFor children: behavioral assessments, depression screening for adolescents, and alcohol and drug use assessmentsMHA is the nation's leading community-based network dedicated to helping Americans achieve wellness by living mentally healthier lives

Capitol Hill Day May 7, 2014 in Washington, D.C.Mental Health America is partnering with the National Council for Behavioral Health to advocate for mental healthStar speakers, informational workshops, and a chance to meet with your Members of CongressLobby, lobby, and more lobbyingUsually interest groups that lobby for increases in homeless healthcare are volunteer or non-profit organizations. These groups have less lobbying power than other companies/groups because of the fact they have less money. When competing for votes it is beneficial to have more money.

Eight tips for a successful lobby visit:Make an appointmentPrepare for the visitBe punctual and positiveFocus the meetingListen and gather informationMake a specific requestFollow upExpress your thankswww.facebook.com/thispageisaboutwordsWe're supposed to leave our personal judgments at the door.

That is especially important in this case because of the sheer amount of negative prejudices that homeless people face. We don't want these ideas to get in the way of patient care.

However, we need to use our judgments to ASSESS as nurses. Assess the needs of our patients based off of what you're seeing and experiencing with each patient.

And finally, make sure our patients know how to take care of themselves when they go home- wherever that may be.